Transitional care is a purposeful, planned process addressing the medical, psychosocial and educational/vocational (holistic) needs of adolescents and young adults as they move from child-centred to adult-oriented healthcare systems. From the perspective of young peoples with juvenile onset rheumatic and musculoskeletal diseases (RMDs), the “health transition” is just one part of the wider set of educational, personal, family and social transitions they make during adolescence. Transition should never be considered as the event of transfer between paediatrics and adult care but as a holistic, age- and developmentally appropriate process. A number of key elements, including the active involvement of AYA themselves, are recognized to be important in transition and are detailed in this chapter.
KeywordsKey components of transition Transition coordinator Multidisciplinary team Implementation
- 8.Howland S, Fisher K. Looking through the patient lens - Improving best practice for young people with juvenile idiopathic arthritis transitioning into adult care. Springerplus. 2015;4 111-015-0888-8. eCollection 2015.Google Scholar
- 15.Ammerlaan JW, van Os-Medendorp H, de Boer-Nijhof NC, Prakken B, Bijlsma JWJ, Kruize AA. The most important needs and preferences of patients for support from health care professionals: a reflective practice on (transitional) care for young adults with Juvenile Idiopathic Arthritis. Patient Educ Couns. 2017;100(10):1961–4.CrossRefGoogle Scholar
- 19.Staa van A. Tien punten programma betere transitie in zorg van kinderzorg naar volwassenenzorg voor jongeren met een chronische aandoening. Op Eigen Benen. 2018.; Available at: https://www.opeigenbenen.nu/wp-content/uploads/2017/10/Tien-punten-programma-Betere-Transitie-in-Zorg-vs-5.pdf
- 20.Cramm JM, Strating MM, Nieboer AP. The role of team climate in improving the quality of chronic care delivery: a longitudinal study among professionals working with chronically ill adolescents in transitional care programmes. BMJ Open. 2014;4(5):e005369. https://doi.org/10.1136/bmjopen-2014-005369.CrossRefGoogle Scholar
- 21.Woolf A, European Union of Medical Specialists Section of Rheumatology/European Board of R. Healthcare services for those with musculoskeletal conditions: a rheumatology service. Recommendations of the European Union of Medical Specialists Section of Rheumatology/European Board of Rheumatology 2006. Ann Rheum Dis. 2007;66:293–301.CrossRefGoogle Scholar
- 24.Grol R, Wensing M. Implementation and improvement of patient care. 5th ed: Reed Business Education. Amsterdam, The Netherlands; 2013.Google Scholar